Dozens of babies died or were left brain damaged as a result of poor care at one of England’s biggest NHS trusts, a “harrowing” report has found.
A damning inquiry has concluded that up to 45 babies who died could have survived if standards of maternity care had been better at East Kent Hospitals University NHS Foundation Trust.
Dr Bill Kirkup, chairman of the independent inquiry into the trust said his panel heard “harrowing” accounts from families receiving “suboptimal” care.
The report stated: “An overriding theme, raised us with time and time again, is the failure of the trust’s staff to take notice of women when they raised concerns, when they questioned their care, and when they challenged the decisions that were made about their care.”
Of 202 cases reviewed by experts, it was concluded that the outcome could have been different in 97.
In 69 of these 97 cases, it is predicted the outcome should reasonably have been different and could have been different in a further 28 cases.
Of the 65 baby deaths examined, 45 could have had a different outcome if nationally recognised standards of care had been provided.
When looking at 33 of these 45 cases, the outcome would reasonably expected to have been different, while in a further 12 cases it might have been different.
Meanwhile, in 17 cases of brain damage, 12 (72% of cases) could have had a different outcome if good care had been given, of which nine should reasonably have been expected to have had a different outcome.
In nearly half of all cases examined by the panel, good care could have led to a different outcome for the families.
At a press conference to launch the report, Dr Kirkup, who chaired the Morecambe Bay maternity inquiry, said he had just met with affected families, who displayed “a great deal of emotion and substantial amount of anger”.
He continued: “When I reported on Morecambe Bay maternity services in 2015, I did not imagine that I would be back reporting on a similar set of circumstances seven years later. What has happened in East Kent is deplorable and harrowing.”
He described a culture of “deflection and denial” within NHS trusts when they are questioned about potential cases of substandard care and said this is a “cruel practice” which “needs to be addressed”.
Dr Kirkup continued: “This is a cruel practice that ends up with families being denied the truth.
“That’s a terrible way to treat somebody in the name of protecting your reputation.
“The findings of the investigation are stark and the conclusions are shocking and uncomfortable.”
The investigation further found that when it came to injuries to mothers and the deaths of mothers, the outcome could have been different in 23 out of 32 cases.
In 15 of these 23 cases, the outcome would reasonably have been expected to be different.
In a letter to health secretary Therese Coffey and NHS chief executive Amanda Pritchard, Dr Kirkup said the report told the truth of what had happened and must be “catalyst” for tackling “embedded, deep-rooted problems” in NHS maternity care.
He added: “It is too late to pretend that this is just another one-off, isolated failure, a freak event that will ‘never happen again’.
“Since the report of the Morecambe Bay Investigation in 2015, maternity services have been the subject of more significant policy initiatives than any other service.
“Yet, since then, there have been major service failures in Shrewsbury and Telford, in East Kent, and (it seems) in Nottingham. If we do not begin to tackle this differently, there will be more.”
It comes after the family of Harry Richford, who died a week after being born at the Queen Elizabeth The Queen Mother Hospital in Margate, Kent in 2017, said concerns were repeatedly brushed aside by hospital managers.
The family have long campaigned for answers and the trust was fined £733,000 last year for failures in Harry’s care after he suffered brain damage.
A previous inquest ruled his death was “wholly avoidable” and found more than a dozen areas of concern, including failings in the way an “inexperienced” doctor carried out the delivery, followed by delays in resuscitating him.
One midwife described “panic” during attempts to resuscitate Harry, while a staff nurse said the scene was “chaotic”.
Responding to the new report, Danielle Clark, mother to Noah, whose case is included, said: “People need to be held accountable. Things have got to change. Babies are dying just through bad care and pure neglect.”
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